Latent abnormal fatty acid metabolism in apparently normal perfusion during stress in patients with restenosis after coronary angioplasty: assessment by exercise stress thallium-201 and iodine-123-labeled 15-(p-iodophenyl)-3-R,S-methylpentadecanoic acid-dual myocardial single-photon emission computed tomography

Restenosis is a major problem in patients undergoing coronary angioplasty. Reduced uptake of iodine-123-labeled 15-(p-iodophenyl)-3-R,S-methylpentadecanoic acid (I-BMIPP-123) relatively to thallium-201 (Tl-201) has been attributed to the metabolic damage in the myocardium in patients with coronary artery disease. Therefore, we performed exercise stress Tl-201 and I-BMIPP-123 dual myocardial single-photon emission computed tomography (SPECT) to detect coronary restenosis in 48 patients (35 men and 13 women, mean age 66 +/- 8 years), followed by coronary angiography at follow-up. Patients were divided into 2 groups: those with (n = 24) and without (n = 24) restenosis. Redistribution of Tl-201 was seen more frequently in the restenosis group than in no-restenosis group (58% [14 of 24] vs 8% [2 of 24], p <0.05). Five of 10 patients (50%) with restenosis but without Tl-201 redistribution had Tl-201/I-BMIPP-123 discrepancy during stress. In patients without restenosis, only 1 patient had this discrepancy during stress. Incorporation of Tl-201/I-BMIPP-123 uptake discrepancy during stress significantly improved the sensitivity (58% [14 of 24] to 79% [19 of 24]) with preserved specificity (92% [22 of 24] to 88% [21 of 24]). Exercise stress Tl-201 and I-BMIPP-123 dual myocardial SPECT revealed that latent abnormal fatty acid metabolism may exist in apparently normal perfusion during stress in patients with restenosis after coronary angioplasty. Use of I-BMIPP-123 together with Tl-201 during stress SPECT substantially improved the diagnostic accuracy of restenosis based on Tl-201 redistribution (from 75% to 83%).     

Surgery for hepatocellular carcinoma with tumor thrombus extending into the right atrium: report of a successful resection without the use of cardiopulmonary bypass

Hepatocellular carcinomas, of which the tumor thrombus extends into the right atrium via the inferior vena cava, may soon cause fatal complications. Only surgery can be an effective treatment. This procedure usually needs the aid of cardiopulmonary bypass. We recently experienced a successful surgery to remove thrombus combined with hepatectomy. Reporting the detailed technique, both associated diagnosis and intraoperative management are discussed herein. We were able to perform hepatectomy of tumor thrombus in the right atrium without the use of cardiopulmonary bypass or veno-venous bypass. The tumor thrombus was removed from the right atrium into the suprahepatic inferior vena cava by reducing the liver on the tail side. And after total hepatic vascular exclusion was achieved, the intracaval tumor thrombus and the right lobe of the liver were removed en bloc. The operation took 545 minutes and the total hepatic vascular exclusion period was 32 minutes. The postoperative course was uneventful. There are some key points for this procedure. Preoperative or intraoperative US is essential in judging whether tumor thrombus can be removed from the right atrium into the inferior vena cava by reducing the liver or not. Test clamping of the inferior vena cava prior to total hepatic vascular exclusion will enable us to judge whether veno-venous bypass during total hepatic vascular exclusion is needed or not. Surgery without the use of cardiopulmonary bypass is safe and can be minimally invasive when it is performed with a reliable diagnosis and technique.     

Strictureplasty for short duodenal stenosis in Crohn's disease

Involvement of the gastroduodenum is extremely rare in Crohn's disease. For obstructing duodenal Crohn's disease, bypass procedures have traditionally been selected. However, more recently, strictureplasty has become an acceptable surgical option. We treated two Crohn's disease patients with short proximal duodenal stenosis, using Finney-type strictureplasty. Their postoperative courses were uneventful and they have remained asymptomatic during follow-up periods of more than 5 years, and 4 months, respectively. Owing to the good clinical results of our two patients, we consider strictureplasty to be indicated for short proximal duodenal stenosis in Crohn's disease. Received: October 14, 1999 / Accepted: February 25, 2000     

Multiple small lesions of hepatocellular carcinoma controlled by percutaneous and laparoscopic ethanol injection--a case report

A 61-year-old man was admitted to our clinic for a liver examination. Ultrasonography revealed multiple echo-rich lesions in both lobes. A laparoscopy showed a liver with an irregular surface, and a 3-mm-sized dark reddish lesion on the inferior surface of the right lobe. alpha-Fetoprotein and plasma protein induced by vitamin K absence or antagonist were normal. A liver biopsy specimen obtained from the small lesion by laparoscopy-guide showed a well-differentiated hepatocellular carcinoma with bile formation. Biopsy specimens obtained later from the 2 echo-rich lesions by ultrasonographic-guide were histologically similar to the lesion laparoscopically observed. Laparoscopic ethanol injection and percutaneous ethanol injection were performed as therapeutic procedures. Recurrence of hepatocellular carcinoma at the treated sites was not observed during the 6-year observation period. Thus, laparoscopy might play an important role in the early detection and treatment of hepatocellular carcinomas on the surface of the liver.     

Influence of aortic dissection on the clotting-fibrinolysis system and platelet function

Coagulopathy is still a frequent complication in the surgical treatment of acute aortic dissection. This study was designed to clarify the influence of acute aortic dissection on the clotting-fibrinolysis system and platelet function. From January 1993 to December 1994 21 patients with proven Stanford type B aortic dissection underwent a series of tests and procedures at our institution. There were 6 women and 15 men, aged 37–74 years (mean 62 years). All patients were admitted within 14 days of onset of dissection. No patient had complications requiring surgery and none died during the observation period. We observed a severe inflammatory reaction with activation of the clotting-fibrinolysis system immediately after onset of dissection. The platelet maximum aggregation rates were also decreased transiently after onset of the dissection. D-dimer values remained elevated throughout, the observation period. A rational approach to the surgical treatment of acute aortic dissection should involve coping with its activated clotting-fibrinolysis system and platelet dysfunction in addition to tissue friability.     

Determination of procollagen type I carboxyterminal propeptide in Japanese patients with systemic sclerosis

Our objective was to clarify the relationship between the serum levels of procollagen type I carboxyterminal propeptide (PICP) and the extent of skin sclerosis or pulmonary fibrosis in patients with systemic sclerosis (SSc). Thirty-eight SSc patients and 36 control subjects were examined for serum PICP levels using enzyme-linked immunosorbent assay. SSc patients were divided into two subgroups according to the grade of skin sclerosis. Mean PICP level in the SSc patients was significantly higher than that in the normal controls. In 53% of the SSc patients, the serum PICP levels were elevated more than 3 SD above the mean control value. The SSc patients with elevated serum PICP levels showed a high incidence of pulmonary fibrosis of diffuse skin sclerosis compared to those with normal PICP levels. Moreover, in 17 patients with pulmonary fibrosis there was an increase in the percentage of patients with elevated PICP levels in the group with diffuse SSc compared to that in the limited SSc group. Furthermore, there was a significant negative correlation between PICP levels and partial pressure of arterial oxygen levels (r=−0.744). We conclude that serum PICP levels may be a useful parameter for the evaluation of skin sclerosis and pulmonary fibrosis of SSc patients.     

HLA-B52-positive vasculo-Behçet disease: usefulness of magnetic resonance angiography, ultrasound study, and computed tomographic angiography for the early evaluation of multiarterial lesions

We report a case of HLA-B52-positive Behçet disease accompanied by multiarterial lesions. A 24-year-old woman was suffering from sporadic high fever and recurrent oral and genital ulcers, and laboratory data revealed severe inflammation. A diagnosis of Behçet disease was made. Magnetic resonance angiography, ultrasound study, and computed tomographic angiography demonstrated multiarterial lesions that had caused no symptoms. These noninvasive examinations were extremely useful in evaluating asymptomatic early vascular lesions.     

Radiofrequency ablation of pulmonary tumors and normal lung tissue in swine and rabbits

OBJECTIVE: The purpose of the present study was to examine the following during radiofrequency ablation (RFA): (1) the risk of hemorrhage from intrapulmonary large vessels; (2) the risk of incomplete ablation of pulmonary tumors; and (3) the late effect on lung tissue. MATERIALS AND METHODS: A 17-gauge, cool-tip-type radiofrequency electrode was used. The damage to the vessels and bronchi was examined by the injection of a colored silicone rubber, a liquid compound that hardens after injection. To examine the risk of hemorrhage from intrapulmonary large vessels, RFA was conducted at eight sites near the central pulmonary vessels in two swine. To examine the risk of an incomplete ablation for pulmonary tumors, 10 pulmonary nodules were made from a gelatin mixture in another two swine and were treated by RFA. To examine the late effect on lung tissue, RFA was conducted on the peripheral lung in 10 rabbits, and then the ablated regions were examined on days 1, 7, 14, 21, and 28 after RFA. RESULTS: The use of colored silicone rubber enabled us to examine the intrapulmonary vessels and bronchi for opening and leakage. RFA did not damage the large intrapulmonary vessels, even when they were located within the ablated regions. Lung tissue surrounding the gelatin nodules was hardly ablated over its entire circumference. Six of 10 gelatin nodules (60%) showed nonablated areas on the peripheral edges of the nodules. From 21 days after RFA, the ablated rabbit lung formed noninfectious cavities by communicating with the surrounding bronchi. CONCLUSION: It was improbable for hemorrhage to occur even when RFA was conducted near the large intrapulmonary large vessels. Because an incomplete ablation that left tumor cells at the site of ablation could occur during surgery due to the difficulty of ablating the entire tumor circumference, CT scan-guided RFA would be preferable to a surgical approach for making a safe margin. Cavity formation can occur beginning 21 days after RFA, which should be carefully followed up in a clinical setting to identify infection, especially in immunocompromised patients.